Br MedJ7 1989;299:368-70. Women who sexually abuse children. SIR,-Dr Robert Wilkins's editorial is a useful step towards the goal of doctors becoming "sensi-.
had genital herpes and are thus at risk of a primary infection in pregnancy.6 What useful advice or reassurance can be given on the basis of knowing a woman's antibody state? Doctors should not refuse to test women who are concerned about particular infections. Nevertheless, the implications of any test, including difficulties in interpretation, must be discussed beforehand. But screening is not an appropriate description of tests undertaken in these circumstances -screening is a service offered routinely to all women in which the advantages of testing are not outweighed by the disadvantages. It is unreasonable to offer screening tests for conditions simply because the tests are available, and it is extremely unwise to pursue the piecemeal introduction of screening tests before proper evaluation using recognised criteria. PAT TOOKEY STUART LOGAN CATHERINE S PECKHAM Institute of Child Health, University of London, London WC IN I EH
1 Bull MJV. Maternal and fetal screening for antenatal care. BrMedJ 1990;300:1118-20. (28 April.) 2 Williams KAB, Scott JM, MacFarlane DE, Williamson JMW, Elias-Jones TF, Williams H. Congenital toxoplasmosis: a prospective survey in the west of Scotland.J Infect 1981;3:21929. 3 Anonymous. Screening for congenital cytomegalovirus [Editorial]. Lancet 1989;ii:599-600. 4 Rutter D, Griffiths P, Trompeter RS. Cytomegalic inclusion disease after recurrent maternal infection. Lancet 1985;ii: 1 182. 5 British Paediatric Surveillance Unit. Third annual report 1988-89. London: British Paediatric Surveillance Unit, 1989:5. 6 Ades AE, Peckham CS, Dale GE, Best JM, Jeansson S. Prevalence of antibodies to herpes simplex virus types I and 2 in pregnant women, and estimated rates of infection. J Epidemiol Communitv Health 1989;43:53-60. 7 Wilson JIMC, Jungner G. Principles and practice of screening for disease. Publ Health Pap 1968;No 34.
SIR,-I am pleased that Dr M J V Bull recognises that women are concerned about toxoplasmosis during pregnancy and is prepared to offer them antenatal screening.' But this pragmatic position creates as many problems as it solves. Undoubtedly, the news media have increased public awareness of the disastrous effects of toxoplasmosis during pregnancy. General practitioners, obstetricians, and laboratory staff can all testify to a dramatic increase in requests for testing. For a consumer led society Dr Bull's approach should be sufficient but instead it seems to be sloppy medicine. It is illogical to offer screening only to those patients who are worried. If screening is cost effective it should be offered to all pregnant women, not only to those who are aware of the risks of infection. The evidence for such screening's cost benefit is strong,2 but some people remain to be convinced. Consequently screening is not funded properly and is offered only to the informed. This unsatisfactory approach will miss many infections as most toxoplasma infections are asymptomatic or non-specific.23 More worryingly, when clinicians and laboratory staff cannot cope with the increased workload they will have to charge. Such a private scheme would probably be more expensive than a government funded scheme and substantially less effective. Irrespective of whether there is a screening programme pregnant women should be given advice on how to avoid infection. Such advice will probably be more acceptable if it is combined with routine testing.3 In France and Austria pregnant women have been routinely tested for toxoplasma infection for the past 10 years and are more aware of the importance of the infection. Other European countries are considering routine antenatal screen-
ing. It is time that there was a large pilot scheme in Britain to assess routine antenatal screening for toxoplasmosis. Tardiness will result in ad hoc
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schemes, to the detriment of many and the frustration of most. D 0 HO-YEN
Scottish Toxoplasma Reference Laboratory, Raigmore Hospital, Inxverness IV2 3UJ 1 Bull MIJV. Slaternal and fetal screening for antenatal care. Br MedJ 1990;300:1118-20. (28 April.) 2 Joss AWL, Chatterton JMW, Ho-Yen DO. Congenital toxoplasmosis: to screen or not to screen? Public Health 1990;104: 9-20. 3 Ho-Yen DO, Chatterton JMW. Congenital toxoplasmosis: why and how to screen. Reviews in Medical Microbtology (in press).
Monoamine oxidase inhibitors and low alcohol or alcohol free drinks SIR,-Dr Peter Tyrer rightly advises that it is relatively safe to take tricyclic antidepressants with low alcohol or alcohol free drinks.' Unfortunately, the question refers to antidepressant drugs in general -a group that includes monoamine oxidase inhibitors- and not merely tricyclics. Drinks of this type may contain sufficient tyramine to initiate a full blown "cheese effect" in patients taking monoamine oxidase inhibitors and should best be avoided by such patients.2 M SANDLER
We are certain that this level of workload could be elicited from any comparatively affluent or otherwise privileged practices. There is little doubt that this aspect of our contractual obligation has grown steadily over the years. Contributory factors include an aging population and improved communications (telephone privatisation increased the number of donmestic telephone lines by around 20%, and there was a concommitant increase in out of hours calls at this time). Our impression is that the more facilities and services that are afforded to patients the greater the expectation, and the greater the demand for attention out of hours. This is the considerable price we are having to pay for offering an accessible and personal medical service. ANDREW ORR JOHN GRIFFITH Montrose DD1O 8LE
DONALD MAcNEILL ALAN BEGG
1 Pitts J, Whitby M. Out of hours workload of a suburban general practice: deprivation or expectation. Br Med J 1990;300: 1113-5. (28 April.) 2 Livingstone AE, Jewell JA, Robson J. Twenty four hour care in inner cities: two years' out of hours workload in east London general practice. Br MedJ7 1989;299:368-70.
Women who sexually abuse children
Queen Charlotte's and Chelsea Hospital, London W6 OXG 1 Tyrer P. Any questions. BrMedJ 1990;300:1328. (19 May.) 2 Draper R, Sandler M, Walker PL. Clinical curio: monoamine oxidase inhibitors and non-alcoholic beer. Br Med J 1984; 289:308.
AUTHOR'S REPLY,-Before responding to the question asked I checked with four of the major companies that sell low alcohol products. All of the companies reassured me that their current products contain insignificant amounts of tyramine and thus should not arouse fears of interaction with monoamine oxidase inhibitors. Independent checks, however, by investigators such as Professor Sandler would be necessary for full reassurance. PETER TYRER
St Charles' Hospital, London W10 6DZ
Out of hours workload in general practice: deprivation or expectation? SIR,-Drs John Pitts and Margaret Whitby have questioned the often made assertion that practices in areas of social deprivation have higher rates of out of hours working than those in more privileged locations. ' From a Scottish seaside semirural practice, which some might regard as being tranquil if not idyllic, we can offer directly comparable statistics in support of their argument. Although our practice (list 6576) is half the size of that in Hythe, it is similar and has similar commitments to the casualty and maternity departments of the local general practitioner hospital. The one salient difference is that we have 19 5% of our patients over 65, against their 14%: this may partially explain our greater workload than theirs (see table). Comparison of out of hours patient contacts/lOOC patientsl year in three practices. The Montrose and Hythe figures include casualty work Montrose 1989 Total contact rate Total visiting rate Contact rateat night Visiting rate at night
299 185 53 31
Hythe East London 1987-8' 1989' 273
152 37 20
219 128 31 8
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SIR,-Dr Robert Wilkins's editorial is a useful step towards the goal of doctors becoming "sensitised to the extent of sexual abuse by women."' His call for further research is well founded but at the same time overlooks some of the insights that have already been achieved, particularly about motivation to abuse and the efficacy of treatment. At the Portman Clinic, London, for more than 50 years we have been treating patients who suffer from sexual perversions or who engage in acts of delinquency and crime. Yet only in the past 15 years have we been able to detect and diagnose accurately female sexual perversions, including the sexual abuse of children. This experience has shown, inter alia, that there is in general an important distinction between male and female sexual perversions. Men use their reproductive organs-namely, their penises-to carry out their perversions against an outside target. Women also use their reproductive organs (which are more widely spread) for perversions, but these are aimed at themselves or at their own creations-that is, their babies. The misassessment that what applies to male perversions applies equally to female has led to some women being so misunderstood as to be denied the treatment they need and for which they sometimes plead. Such attitudes are among the reasons why it is taking so long for the profession, let alone the public, to accept that some mothers sexually abuse their children. This lack of acknowledgment has a parallel with the failure in the 1960s to recognise that battered children's injuries could be caused by their mothers. A second insight concerns the propensity of sexual abuse to be perpetuated through mothers. A significant percentage of the patients we see-and this refers to both men and women-are themselves the victims of sexual abuse as children. Incest committed by fathers is commoner than incest committed by mothers but this condition in men is sometimes traceable to their mother's perverting actions, which I call "perversogenic." Doctors and psychiatrists need to be on the lookout for this. The identification of this and similar conditions and hence the efficacy of the recommendation for treatment depend crucially on the proper integrated training of all professionals concerned: a multidisciplinary approach works best. That is why the Portman Clinic has recently launched the first course in the United Kingdom in forensic psychotherapy, under the auspices of the 1527
